Surgery: Benign Breast Disease Flashcards
Anatomy of the breast
- Modified sweat glands
- Composed of 15-20 lobules of glandular tissue which is embedded in fat
- Each lobule drains into a lactiferous duct
- Then individually open on the nipple
How to explore the symptoms of a breast lump while taking a history?
A breast lump
- How long have you had the lump?
- Has it changed in size?
- Does it alter with your periods?
- Is it tender?
- Is there any change in the overlying skin?
Considerations while thinking about the symptoms of breast pain
Breast pain
- Common
- Is it cyclical?
- Pubertal/peri-menopausal
- Referred pain
Considerations while thinking about nipple change (what to ask for)
3 problems
Nipple change
•Eczema
- Is the eczema on the nipple or the areola?
- Ask about other areas of eczema
•Retraction
•Is this longstanding or a new symptom?
•Discharge
- 5% associated with cancer
- Is the discharge spontaneous or induced?
- Is the discharge from one or both breasts?
- Frequency
- Colour
- Recent pregnancy
- Menopausal status/age
Risk factors for breast cancer
•Age → 8 out of 10 cancers are diagnosed in the 50-64 age group
- Reproductive history
- Early age of menarche
- Late age of first child
- Nulliparous women
- Bottle rather than breast feeding
- Delayed menopause
- Family history
- 5% of breast cancer is associated with a genetic abnormality
- Particularly concerned about 1st/2nd degree relatives with cancers at an early age
- Other risk factors
- OCP/HRT
- Radiation exposure
- Alcohol intake
What to ask about in a ‘previous breast history’ section (5)
- Previous breast cancer
- Previous benign disease
- Previous breast surgery
- Recent mammograms (including screening programme)
- Previous chest wall radiotherapy
What else (apart from on breast) look for/assess while clinical examination?
- Axillary and supraclavicular lymph nodes
- Bony tenderness
- Hepatomegaly
- Ascites
Radiological investigations for breast problems
•Radiological
- Mammogram (X-ray)
- Ultrasound scan (specific area)
- MRI (lobular, mammographically occult, dense breasts, multifocal or bilateral disease)
- CT and Bone scan (systemic disease)
Pathological investigations for a suspected breast cancer
- Cytology (Fine Needle Aspiration cytology)
- Core Biopsy
- Vacuum-assisted biopsy/excision
- Excision biopsy
Systems/scores used in each component of a triple assessment
Name that investigation
Mammogram
Name the mode of investigation
Core biopsy
Categories of benign breast disease
- Congenital problems
- Nipple discharge
- Infection/mastitis, abscess
- Pain /mastalgia
- Gynaecomastia
- Benign neoplasms
Possible congenital problems of the breast
- Extra nipples and breasts
- Absence or hypoplasia of the breast (Poland’s syndrome)
- Chest wall abnormalities
- Accessory tissue
Nipple discharge can be… (2)
- Bilateral/Unilateral
- Single Duct/ Multiple ducts
Colours of nipple discharge and what they possibly imply
- Clear: physiological
- Milky: Pregnancy/ pituitary adenoma
- Brown/green: mammary duct ectasia
- Bloody: Intraductal papilloma 90%, Cancer 10%
Algorithm for a general management of a nipple discharge
What’s that?
Breast abscess
Breast abscess
- types
- association (1)
- what’s seen on examination
- management
Infection → pus accumulation → mass formaton
Management: aspiration and antibiotic therapy
*breastfeeding can continue from the other breast
What is mastitis caused by?
- Mastitis describes inflammation of the breast tissue
- the most common cause is from infection→ S. Aureus, but can occasionally be granulomatous
What’s that?
How can mastitis be classified (2)
Classified by lactational status
-
Lactational mastitis (more common) → usually presents during the first 3 months of breastfeeding or during weaning
- It is associated with cracked nipples and milk stasis (often caused by poor feeding technique), and is more common with the first child
-
Non-lactational mastitis (less common) often in women with other conditions such as duct ectasia, as a peri-ductal mastitis
- Tobacco smoking is an important risk factor, causing damage to the sub-areolar duct walls and predisposing to bacterial infection
Management of mastitis
- best managed with systemic antibiotic therapy and simple analgesics
- In lactational mastitis, continued milk drainage or feeding is recommended
- Cessation of breastfeeding using dopamine agonists (such as Cabergoline) can be considered in women with persistent or multiple areas of infection
What to ask about if a patient presents with breast pain (mastalgia)
- Age
- Unilateral or bilateral
- Site
- Cyclical or non cyclical
- Contraceptive pills and HRT
- Associated lumps
- Examine for lumps and tenderness
- Reassure/review/refer